Methods and devices for laparoscopic surgery

ABSTRACT

Two part laparoscopic tools and surgical methods using such tools are presented. The tools and methods enable use of multiple surgical tools each having wide tool heads to be used in a body cavity using a single wide trocar and one or more narrow incisions, thereby reducing surgical risk and enhancing patient comfort and shortening recovery time. Additional instruments for facilitating laparoscopic surgery are also presented.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No. 14/831,424, filed Aug. 20, 2015, which is a continuation of U.S. application Ser. No. 12/781,831, filed on May 18, 2010, which claims the benefit of priority under 35 U.S.C. §119(e) of U.S. Provisional Application No. 61/179,413, filed on May 19, 2009, the contents of which are incorporated herein by reference in their entireties.

FIELD AND BACKGROUND OF THE INVENTION

The present invention, in some embodiments thereof, relates to devices and methods for performing laparoscopic surgery.

Laparoscopic surgery (one form of minimally invasive surgery (MIS), also known as band-aid surgery, keyhole surgery, or pinhole surgery) is a modern surgical technique with many advantages over traditional open surgical methods. The first use of this approach in order to perform a cholecystectomy was in 1987. Since that time, the procedure has gained popularity and is now regularly used in many different operations within the abdominal and pelvic cavities as well as for thoracoscopic and orthopedic surgery.

In existing laparoscopic methods, a variety of different instruments are used, including graspers, scissors, coagulation devices, harmonic scalpels, needle holders, cameras, suction devices and so on. A plurality of such instruments may be required in a single procedure, with each instrument requiring its own trocar, which both acts as an entry port and facilitates manipulation of the devices within the abdominal cavity or other operative site. In general, laparoscopic operations are usually performed by inserting 2-6 trocars (ports) into the abdominal cavity, each through an incision in the skin.

The trocars usually range in size from 5 mm to 12 mm in diameter, each serving as an introduction channel for one or more surgical tools. However, the use of trocars carries risks during both insertion and removal. The risks include:

-   -   damage to blood vessels in the abdominal walls (particularly in         overweight patients);     -   damage to fascial tissues;     -   extended and painful recovery period;     -   visible scarring;     -   relatively high cost;     -   time consuming; and     -   post-operative ventral hernia (POVH), particularly when the         larger trocars are used.

Most of the aforementioned risks and disadvantages are associated with the relatively large size of the incision required for trocar insertion.

SUMMARY OF THE INVENTION

The present invention, in some embodiments thereof, relates to devices and methods for performing laparoscopic surgery. More specifically, the present invention provides two-part laparoscopic tools which may be inserted into the body using fewer and/or smaller incisions than those used according to methods of prior art, and other tools for facilitating laparoscopic surgery. Embodiments of the invention significantly reduce surgical risks, simplify surgical procedures, and facilitate rapid patient recovery.

The methods include performing laparoscopic interventions using one or more multi-part instruments, wherein each instrument comprises a shaft (optionally with handle) and one or more operating tools (also called “operating heads” and “operating tool heads”) attachable to that shaft. The shafts have a cross-section considerably smaller than most laparoscopic tools of prior art and are designed for direct insertion into the body cavity by puncture penetration or through a relatively small incision, rather than through a conventional laparoscopic port. The handles comprise a screw thread or other attaching mechanism at their distal ends, suitable for attaching an operating head thereto.

In the following the term “wide trocar” refers to a trocar wide enough to enable passage of an operating tool. A typical internal diameter of a wide trocar would be 4 mm or larger, though that size is not to be considered limiting. In the following the term “narrow trocar” refers to a trocar only wide enough to enable passage of a shaft to which an operating tool may be attached. A typical internal diameter of a “narrow trocar” would be 3 mm or less, though that size should not be considered limiting.

Various embodiments presented herein enable providing a plurality of operating tools each connected to an individual shaft and able to be operated independently, using only a single wide trocar, by introducing a plurality of operating tools into the body cavity through the wide trocar, and introducing shafts for those operating tools either through narrow trocars or by using a shaft (optionally with an inserted stiffener) to directly puncturing the cavity wall, thereby creating openings substantially similar in size to the diameter of the shaft. Such openings are considerably smaller than the opening required for a wide trocar, and consequently are less damaging and provide fewer complications, shortened recovery time and less bleeding and less scarring.

Embodiments presented herein include methods for attaching an operating tool to shaft and optionally also to a manipulating handle, including:

a) introducing a distal portion of a shaft into a body cavity, for example by puncturing a wall of the cavity or by introducing the handle through the wall by means of a narrow trocar, introducing an operating tool into the body cavity through a wide trocar, and connecting tool to shaft within the body cavity,

b) introducing a distal portion of a shaft into a body cavity, for example by puncturing a wall of the cavity or by introducing the handle through the wall by means of a narrow trocar, extending the distal shaft portion towards and into a wide trocar, advancing the distal shaft portion through the wide trocar so that the distal shaft portion exits the body cavity through the wide trocar, attaching an operating tool to that distal shaft portion while the distal shaft portion is outside the body, and then withdrawing the shaft so that the attached operating tool is retracted into the body cavity where it can be used, and

c) attaching an operating tool to a shaft, the shaft optionally having a sharp proximal end, introducing the shaft into a wide trocar, extending it towards an inner portion of a body cavity wall, causing the shaft to traverse to body cavity wall so that the proximal shaft extends outside the body cavity, connecting a handle to the shaft portion which is external to the body cavity, and withdrawing the shaft far enough from the body so that the operating tool is drawn through the wide trocar and into the body cavity, where it can be used.

The operating tools (also called “operating heads” herein) may be any surgical tools, including (but not limited to) graspers, scissors, coagulation devices, harmonic scalpels, LigaSure, needle holders, ligatures, cameras and suction devices. The operating heads may optionally have shaft diameters similar to, or larger than, those of conventional laparoscopic tools. According to some embodiments of methods of use, a plurality of these operating heads may be inserted into the body (e.g. sequentially, through a single trocar port of conventional design, or Gastro-Colonoscopically using a Natural Orifice Transluminal Endoscopic Surgery (NOTES) instrument) and may be mated with and attached to their shafts within the body cavity. In alternative embodiments one or more of such shafts may be inserted into the body cavity, extended out of the body cavity (e.g. sequentially) through a single trocar or a reduced number of trocars, attached to an operating head outside the body, and thence drawn back into the body cavity through the trocar. With either of these methods, the result is a plurality of narrow shafts penetrated into the body cavity through punctures or insertions which are smaller than typical trocar diameters, each shaft mated to an operating head, which may be any conventional surgical tool of normal diameter and capabilities. Additional operating heads may be introduced into the body cavity and operating heads may be switched and exchanged, all within the body cavity, during the course of an operation. A plurality of surgical tools are thereby made available for manipulation and use within a body cavity, though only a reduced number of trocars (optionally only one) have been used.

Some embodiments of the present invention further comprise

-   -   tools for managing a plurality of operating heads within the         body cavity, comprising a plurality of connecting elements each         able to hold an operating head, and further comprising a         penetrating element operable to penetrate a body wall from         within the body cavity, and to extend beyond the body where it         may be grasped and immobilized from outside the body;     -   tools for inserting operating heads into the body cavity and/or         for removing operating heads from a body cavity, optionally         implemented as a sheath adaptable over a camera assembly         introduced into a body through a trocar;     -   tools for removing body tissues or other objects from the body         cavity during an intervention, comprising a sheath (optionally         adaptable over a camera assembly introduced into the body         through a trocar) and a rolled or folded bag which may be         introduced into the body cavity through the sheath, unrolled or         unfolded within the body cavity, filled with materials to be         extracted, and then withdrawn from the body through the trocar;     -   tools for stabilizing and/or immobilizing and/or positioning         body organs or other tissues during a surgical intervention         comprising a narrow shaft having a distal portion insertable         into the body cavity and connectable to an operating head, and a         stabilizing/positioning mechanism connected proximal portion of         the shaft outside the body and designed to stabilize the shaft         in a selected position; and     -   several grasper designs with detachable heads, some including a         head mechanism presenting advantages over head mechanisms known         to prior art.

It is noted embodiments of the present invention include (and are not limited to) the above-listed components and embodiments used both separately and/or in concert, and further include additional components and embodiments as detailed below. It is further noted that the “wide” and “narrow” tools described in detail below may be used individually or in sets of several such tools used individually and/or in concert, and that one or more “wide” tools may be used alone or in concert with one or more “narrow” tools. It is further noted that the invention is not limited to the specific exemplary uses described for the disclosed devices, and that the invention is also not limited to the specifically described exemplary tool examples described as being used to perform the disclosed methods.

Unless otherwise defined, all technical and/or scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of embodiments of the invention, exemplary methods and/or materials are described below. In case of conflict, the patent specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and are not intended to be necessarily limiting.

BRIEF DESCRIPTION OF THE DRAWINGS

Some embodiments of the invention are herein described, by way of example only, with reference to the accompanying drawings. With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of embodiments of the invention. In this regard, the description taken with the drawings makes apparent to those skilled in the art how embodiments of the invention may be practiced.

In the drawings:

FIGS. 1A and 1B are simplified schematics of a two-part laparoscopic tool, according to an embodiment of the present invention;

FIGS. 2, 3, 4 and 5 are simplified schematics showing components of the tool shown in FIGS. 1A and 1B;

FIGS. 6A and 6B are simplified schematics showing a hollow grasper head;

FIGS. 6C, 6D and 6E show uses for the hollow grasper head shown in FIGS. 6A and 6B, according to embodiments of the present invention;

FIG. 7 is a schematic of a laparoscopic tool with electrical functions, according to an embodiment of the present invention;

FIG. 8 is a narrow laparoscopic tool according to an embodiment of the present invention;

FIG. 9 is a grasper head showing opening and closing of the grasper, according to an embodiment of the present invention;

FIG. 10 shows several views of an additional construction of a grasper head according to an embodiment of the present invention;

FIGS. 11A, 11B, 11C and 11D show details of connection between a shaft and a handle, according to an embodiment of the present invention;

FIG. 12 presents a immobilization device for surgery according to an embodiment of the present invention;

FIG. 13 presents a tool for manipulating operating heads within a body cavity;

FIGS. 14 and 15 present examples of the use of the tool shown in FIG. 13, according to an embodiment of the present invention;

FIGS. 16, 17 and 18 present several embodiments of a tool for removing materials from a body cavity, according to an embodiment of the present invention;

FIG. 19 presents a tool for organizing treatment heads within a body cavity;

FIGS. 20, 21 and 22 present stages in the use of the tool shown in FIG. 19, according to an embodiment of the present invention;

FIG. 23 presents a method for attaching a treatment head to a shaft according to an embodiment of the present invention;

FIGS. 24, 25, 26, 27, 28 and 29 present stages in a process for introducing and using a surgical tool with a wide head in a body cavity using only a small incision, according to an embodiment of the present invention;

FIG. 30 presents an optional enhancement to the method shown in FIGS. 24-29, according to an embodiment of the present invention; and

FIGS. 31, 32, 33, 34, 35, 36, 37, 38 and 39 present aspects of a surgical procedure whereby a tool with wide operating head and narrow shaft may be introduced into a body cavity, according to an embodiment of the present invention.

DETAILED DESCRIPTION

The present invention, in some embodiments thereof, relates to devices and methods for performing laparoscopic surgery. More specifically, the present invention provides two-part laparoscopic tools which may be inserted into the body using fewer and/or smaller incisions than those used according to methods of prior art, and other tools for facilitating laparoscopic surgery. Embodiments of the invention significantly reduce surgical risks, simplify surgical procedures, and facilitate rapid patient recovery.

Before explaining at least one embodiment of the invention in detail, it is to be understood that the invention is not necessarily limited in its application to the details of construction and the arrangement of the components and/or methods set forth in the following description and/or illustrated in the drawings and/or the Examples. The invention is capable of other embodiments or of being practiced or carried out in various ways.

It is expected that during the life of a patent maturing from this application many relevant laparoscopic tools will be developed and the scope of the terms “laparoscopic tool”, “operating tool” and “operating head” are intended to include all such new technologies a priori.

The terms “comprises”, “comprising”, “includes”, “including”, “having” and their conjugates mean “including but not limited to”.

The term “consisting of means “including and limited to”.

As used herein, the singular form “a”, “an” and “the” include plural references unless the context clearly dictates otherwise. For example, the term “a compound” or “at least one compound” may include a plurality of compounds, including mixtures thereof.

As used herein the term “method” refers to manners, means, techniques and procedures for accomplishing a given task including, but not limited to, those manners, means, techniques and procedures either known to, or readily developed from known manners, means, techniques and procedures by practitioners of the chemical, pharmacological, biological, biochemical and medical arts.

As used herein, the term “treating” includes abrogating, substantially inhibiting, slowing or reversing the progression of a condition, substantially ameliorating clinical or aesthetical symptoms of a condition or substantially preventing the appearance of clinical or aesthetical symptoms of a condition.

According to some embodiments of the invention there is presented a method for inserting and removing surgical instruments during a laparoscopic procedure in the body cavity of a subject, comprising:

-   -   inserting a surgical instrument (a grasper, for example)         constructed of two separate parts, a distal operating head         inserted into a body cavity through a conventional laparoscopic         port, by use of a Natural Orifice Transluminal Endoscopic         Surgery (NOTES) instrument, or by some similar method, and a         proximal shaft directly inserted into a body cavity through a         stab incision made in the wall of the body cavity     -   connecting the two parts of the instrument;     -   use of the instrument within the body cavity     -   separation of the two parts following their use;     -   withdrawal of the shaft through its stab incision; and     -   withdrawing of the distal operating head through the port, NOTES         instrument, or similar device.

Connecting and separating distal and proximal portions of the device may be performed with the assistance of a conventional grasper inserted through a trocar.

In some embodiments of the invention a surgical kit comprises a “wide tool” and one or more “narrow tools”.

FIG. 1A presents an exemplary embodiment of a wide tool 99, comprising a shaft 100 with a sharp distal end 110 capable of penetrating a body wall, and a detachable head 200. FIG. 1B shows a wide tool with detachable head 200 attached.

In some embodiments the shaft of the wide tool is inserted into a body cavity through the cavity wall, and the distal head of the wide tool is inserted into the body cavity through a trocar and connected to the wide tool shaft by manipulation by a grasper or other tool inserted through a trocar. In other embodiments the distal portion of the wide tool may be caused to traverse a portion of the body cavity, and exit the cavity through a trocar, where the wide tool head can be connected to the wide tool shaft, which is then retracted into the body cavity. In yet other embodiments the wide tool with head attached may be inserted into the body cavity through a trocar.

Once the wide tool head is connected to the wide tool shaft and positioned in the body cavity, the wide tool can be used as described below to connect additional operating heads to additional tools having shafts introduced (by puncture or very small incisions) into the body cavity. These may be additional wide tools and/or “narrow tools” as described below.

As may be seen in the exemplary embodiment shown in FIG. 1, the shaft of the wide tool may be implemented with a proximal handle 300 shaped similarly to a scissor, with one leg of the scissor attached to the outside of the shaft, and a second leg attached on an actuating rod or actuating cord passing the length of the shaft and providing means for manipulating an operating head when attached thereto by pulling or pushing on the actuating rod or cord and causing it to move backward or forward with respect to the body of the shaft.

FIG. 2 shows a portion of a distal part of such a shaft, showing at “A” a passageway 120 for such an actuating cord 125 or rod 127, at “B” a connector 130 for fluid (e.g. irrigation or suction), and at “C” a passageway 140 for a stiffening rod 150. FIG. 3 shows such a stiffening rod 150 positioned alongside the shaft 100 of a wide tool 99, and FIG. 4 shows the stiffening rod 150 inserted therein. Such a stiffening rod can be inserted in the shaft 100 to stiffen and reinforce the shaft, for example when the shaft is caused to penetrate by force through a body wall or other tissue. The stiffening rod can then be removed, leaving an empty passageway 140 through which fluids can be caused to flow (e.g. for suction or irrigation), or which may be used for other purposes such as passing objects therethrough.

FIG. 5 presents an additional embodiment where similar elements are presented in a slightly different configuration. It is noted that the small passage 120, described above as used for passage of an actuating cord 125 or rod 127, can be used for other purposes, such as for passage of an electrical connection 129. Additional conduits within the shaft may be supplied as well.

The wide tool may be provided with a solid grasper head, or with a grasper head 210 comprising hollow portions 220 which can be used as conduits for fluids. Such a head 210, comprising a hollow 220, is shown in FIG. 6A, and a detail view of the hollow portion of such a head is shown in FIG. 6B. This hollow portion 220 can be made continuous with the passage 140 shown in FIG. 2, or with another conduit in the shaft, to enable irrigation, suction, or some similar fluid-related activity. It is noted that although a grasper head with a hollow portion is shown in the figures in the context of tools with detachable heads as described above, graspers and similar surgical tools which comprise hollow portions and are capable of implementing suction activity or irrigation activity in addition to grasping may also be implemented in surgical instruments wherein the grasper head is permanently attached to its shaft.

FIGS. 6C, 6D, and 6E show successive stages of fluid flow in the case of suction being applied at point “B” of FIG. 2.

Optionally the wide tool may comprise an electrical power connection, and portions of the shaft may be constructed of insulating materials or may be covered by insulating materials, as appropriate. Electrical tools 270 may be positioned at the operating head or may be incorporated in the shaft. An example is provided in FIG. 7, which presents a wide tool configured as a coagulator 272.

FIG. 8 presents a partial view of a “narrow tool” 101, one or more of which are supplied together with at least one “wide tool” to form a kit, in some embodiments of the present invention. A narrow tool is similar to a wide tool in that it comprises a shaft which comprises a distal end sharp enough to penetrate tissue, a separable operating head useful for performing a useful function during a surgical procedure, and an attachment configuration (for example, screw threads) enabling to attach and the operating head to a distal portion of the shaft, and to detach it therefrom. In some embodiments the narrow tube comprises a conduit through which a wire and/or an activating rod or cord may be passed, which wire or rod or cord may be used to control or activate the operating head or a portion thereof. Such a conduit is seen positioned in an upper portion of that part of a narrow tool shaft pictured in FIG. 8.

It is an advantage of the narrow tool that it may be made extremely thin: in some embodiments the diameter of a narrow tool is between 1 and 3 mm. (Note that these dimensions are given by way of example, and are not to be considered limiting.) Thin shafts of such narrow dimensions can be caused to penetrate through an abdominal wall (or into any other body cavity) with a minimum of damage to tissues through which they pass. In an exemplary method of use, a wide tool is introduced into a body cavity as described above, an operating head for a narrow tool is introduced into a body cavity through a trocar, and the wide tool is used to grasp the detached narrow-tool head and to attach it to the narrow tool shaft. In this manner one or many narrow tools can be introduced into the body cavity and used within the cavity with only minimal damage to the cavity walls. Narrow tools so introduced are similar to standard laparoscopic tools and can be used by a surgeon with little or no special training.

In some embodiments the operating head is constructed of two parts, a base part connected to the shaft (e.g. to a wide tool shaft or to a narrow tool shaft), and a second moveable part connected to an activating rod positioned in a conduit within the shaft. Moving the activating rod forward and backward has the effect of moving the moveable head part with respect to the base head part, for example opening and closing a grasper as shown in FIG. 9.

In an alternative construction shown in FIG. 10, two moveable parts each connected to a common activating rod are also connected to a fixed part of a shaft. Forward and backward movement of the activating rod with respect to the shaft has the effect of closing and opening the moveable portions of the grasper, as shown in the Figure.

A further alternative construction is presented in FIG. 11, which shows a configuration in which an external activating rod connects to an external portion of an operating head, and an internal activating rod, able to advance and retract within the external portion, connects to an internal portion of the operating head. Advancing and retracting the internal rod with respect to the external portion causes opening and closing of the jaws of the grasper. Also of interest in the Figure: note the form of the distal portion of the shaft 100 in FIGS. 11A and 11D, which distal portion is pointed 102 to facilitate penetration of tissues, but which also comprises screw threads 104 enabling connection between shaft and head. Note also the matching screw threads 103 on outer and inner portions of the operating head, as shown in FIGS. 11B and 11D.

Surgical Support Tools:

Physical Support Structure: In some embodiments of the invention there is provided a support structure 500 which enables to physically support or hold organs or parts of organs or other tissues in particular positions, to enable surgical work to proceed on those organs or tissues, or on organs or tissues in their vicinity. FIG. 12 provides a view of an embodiment where a wide or more typically a narrow tool is used for this purpose. The distal portion of the tube is made to penetrate into the body cavity, the operating head 200 is attached as described above, and the operating head 200 (in the form of a grasper or other tool) is made to seize and hold a portion of the organ or tissues whose support or immobilization is desired. As shown in the figure, an external support device 500 surrounding or otherwise connected to a proximal portion of the tool shaft 100, outside the body cavity, is adjustable and may be adjusted to maintain that proximal portion at a desired position and angle with respect to the body. (In the exemplary embodiment shown in the figure, a tripod 502 or multi-legged shape 504 with adjustable-length legs 506 is used.) Fixing the position of the proximal portion, external to the body, also fixes the position of the distal portion internal to the body, and thereby fixes also the position of the tissue or organ grasped by the head.

Tool for removal of operating heads: FIGS. 13-15 present a tool for removal of operating heads from within the body cavity. FIG. 13 shows the head removal tool in the form of a sleeve 600 formed to fit on a camera or other visualization device 610 introducible into a body cavity through a trocar 620. At the end of the operation or whenever desired, the visualization device may be withdrawn from a trocar, a sleeve 600 added to the device as shown in FIG. 13, and the device reinserted. In use sleeve 600 may be extended beyond the visualization device. A wide or narrow tool is used to detach an operating head 200 from a tool, and to position it within or attach it to sleeve 600 as shown in FIG. 14. The visualization device together with sleeve 600 and the attached operating head 200 can then be removed through the trocar as shown in FIG. 15.

Device for Extracting Tissues:

During the course of an operation it is often necessary to provide for removing from a body cavity organs or tissues which have been excised, or to provide from removing devices introduced into the cavity during the operation. FIGS. 16-18 present a device for doing this.

As shown in FIG. 16, a sleeve 600 is provided which is sized and shaped to be adapted to a visualization device 610 insertable into the body through a trocar 620 or other port. An appropriately sized bag 630 is rolled or folded and stored within the sleeve.

When deployment of the bag is desired, the bag 630 may be unrolled or unfolded using a manipulation device (such as narrow or wide tool with grasper head) present in the body cavity. The deployed removal bag 630 is shown in FIG. 17.

In an alternative embodiment, the removal bag may be provided with flexible straps 640 as shown in FIG. 18. The straps may be manipulated to open the bag for use, and the bag may be removed from the body cavity by pulling on the straps, which extend beyond the trocar and may be grasped from outside the body of the patient.

Tool for Managing Operating Heads:

According to a further aspect of embodiments of the invention, there is provided a tool for managing a plurality of operating heads within the body of a patient.

As described above, operating heads may be inserted into a body cavity (e.g. through a trocar) and there may be attached to one or more tool shafts. In some cases it may be desired to have a plurality of operating heads (e.g. a plurality of tools of different types) present within a body cavity, and to alternate use of various heads by attaching and disconnecting them from one or more tool shafts, which shafts remain in place and need not be removed from the cavity nor reinserted therein.

To facilitate this process a tool organizing device is provided, as shown in FIGS. 19-21.

The tool organizing device may be configured as a cartridge magazine, as a rack, as a shelf, as a set of hooks, or in any other convenient configuration.

FIG. 19 shows an exemplary tool rack 650 (a tool organizer device or “head storage tool” is configured as a set of connected hooks) is shown external to the body cavity.

In FIG. 20, the tool organizer device (head storage tool) has been inserted into the body cavity, e.g. through a trocar. To avoid multiplying large body openings, if a single trocar has been installed and is used for passage of a visualization device into a body cavity, passing the tool organizer (or tool operating heads, or other objects) into the cavity may be done, for example, by removing a visualization device from a trocar, passing the organizing device through the trocar into the cavity, and then replacing the visualization device in the trocar.

As shown in the Figure, the tool organizer comprises a penetrating point 660 long enough and sharp enough so that if the device is grasped by a tool within the cavity the penetrating point may be caused to pass from inside the cavity to the outside of the body, where it may be grasped and held by a surgical tool. This has the effect of immobilizing the tool organizer as shown in FIG. 21.

A plurality of operating heads may then be stored in or on the device during an operation, where they are accessible to being taken up by one of the available manipulating tools (e.g. wide tool or narrow tool), yet are kept in order and out of the way of on-going surgical manipulations. This situation is presented in FIG. 22.

Attention is now drawn to FIG. 23 which shows a process whereby an operating head 200 may be attached to a penetrating tool 100 while outside the body, as was mentioned above. This procedure is convenient for attaching an operating head to a wide tool, which wide tool can then be used to attach operating heads to a plurality of narrow tools within the body cavity. However, for convenience, the procedure shown in FIG. 23 can be used to attach heads to narrow tools as well.

As seen in the figure, a shaft 100 is caused to penetrate into a body cavity in which a trocar 620 or similar port has been inserted. The shaft is then directed towards and through the trocar (a visualization device using the trocar may be temporarily removed from it for this purpose), and becomes available outside the body, where the operating head may be attached. The shaft is then withdrawn through the trocar back into the body cavity, where it may be used. A similar procedure can be utilized to remove a head from a shaft before withdrawing the shaft from the body.

Example of a Surgical Procedure Using Tools Described in this Document Removal of an Appendix.

-   -   Insert standard trocar (e.g. trocar of 10 mm diameter) into a         body cavity wall, e.g. in the navel.     -   Insert a visualization modality (e.g. a camera), use it to         survey the body cavity, locate the infected appendix.     -   Insert wide tool directly into lower belly.     -   Temporarily remove visualization device, pass through the distal         portion of wide tool so that it extends beyond the trocar and is         outside the body.     -   Affix operating head to wide tool.     -   Withdraw wide tool through trocar into body cavity, replace         visualization device.     -   Introduce narrow tool into the lower belly above the pubis under         guidance of visualization device.     -   Remove visualization device from trocar, introduce operating         head (e.g. dissector) through trocar, restore visualization         device.     -   Use wide tool to grasp dissector head and affix it to narrow         tool shaft, under guidance of visualization tool.     -   Remove visualization device from trocar, introduce tool         organizer, scissor tool, and a tool for immobilization of the         intestine.     -   Fix tool organizer in a place by holding with wide tool and         causing its penetrating point to penetrate the body wall to a         position outside the body, where it is grabbed by a standard         surgical device, thereby immobilizing it.     -   Mount spare operating heads on the organizing tool.     -   Proceed with the operation, cutting, cauterizing, etc. according         to standard surgical procedures as needed, using the various         tools held in readiness by the tool organizer, and changing         operating heads as needed. Appendix is disconnected from the         body, bleeding is cauterized and/or tied. Scissor head mounted         on one of the shafts and used to cut ligatures.     -   Visualization tool removed, sleeve containing tissue bag is         mounted on visualization device which is returned to place         through the trocar.     -   Bag is opened using narrow tool, appendix placed within bag, bag         and visualization device removed from body through trocar.         Visualization tool replaced in cavity.     -   Operation site is irrigated through hollow portion of wide tool.         Hemostasis checked.     -   Body cavity is irrigated, cleaned, inspected.     -   Head removal tool mounted on visualization tool and used to         remove various operating tools, and (usually last) the tool         organizer.     -   Narrow tool(s) withdrawn from body under observation by         visualization tool. Generally no stitching of the penetration         site is required.     -   Removal of visualization device, then of the trocar. Closing of         the opening through which the trocar was inserted.

Attention is now drawn to FIGS. 24-29 which show additional methods for providing a plurality of operating tools with wide heads within a body cavity having only a single wide opening.

FIG. 24 shows an operating tool 700 with a wide head 720 and a narrow shaft 710 being inserted through a trocar 620 into a body cavity. Note that in the figure the wide operating-tool head 720 is positioned outside the body, and the narrow shaft 710 is inserted through the trocar into that body. If FIG. 25 the trocar, and the tool within it, is seen to be oriented so that the narrow shaft of the tool is aimed towards a selected portion of the outer wall of the body cavity.

FIG. 26 shows the shaft (which may have a sharp end 711) starting to puncture the cavity wall, moving from inside the body cavity towards the outside. A continuation of the process is shown in FIG. 27, in which the shaft has penetrated the cavity wall, and can be grasped from outside the patient's body. The shaft can then be draw sufficiently far outside the patient's body so that the opposite end of the tool, with operating head attached, can be drawn through the trocar and into the body cavity. In the situation shown in FIG. 28, the operating head and distal portion of the tool are within the body cavity, and the tool's shaft is outside the body cavity. FIG. 29 shows a handle attached to the tool, which is now read for surgical work within the body cavity. It the series of figures now described only one tool has been so inserted, but it is to be understood that a plurality of tools may be inserted into the body cavity in this manner, each having only a narrow-diameter puncture penetration of the body cavity wall and a wide operating tool head.

An optional additional embodiment is shown in FIG. 30, where a narrow trocar 740, only slightly larger than the diameter of the tool shaft 710, is positioned on the tool shaft prior to connection of handle 300 to shaft. The trocar can be slid down the shaft and into the puncture hole around the shaft, where it serves to facilitate free motion of the shaft during the surgical procedure and also serves to preserve gas pressure within the body cavity if the body cavity is inflated, as is often the case during surgical procedures.

Attention is now drawn to FIGS. 31-39, which present aspects of a surgical procedure whereby a treatment tool with narrow shaft and relatively wide treatment head can be introduced into a body cavity and manipulated through a narrow incision.

FIG. 31 shows a surgical tool 700 partially introduced through a trocar into a body cavity, with shaft 710 in the body cavity and operating head 720 outside the cavity. A handle 301 which comprises an internal stiffener 370 having a sharp point 372 is shown inserted in the handle 301, outside the body. (The stiffener is shown in dark color)

FIG. 32 shows the handle 301, with stiffener inserted, penetrating into the body cavity wall. In FIG. 33 the stiffener 370 has been removed, the handle 301 remains penetrating the cavity wall. In FIG. 34, the shaft 710 of the tool 700 inserted through the trocar, and the handle 301 inserted through the cavity wall are oriented towards each other, in FIG. 35 they approach each other and in FIG. 36 they connect. Shaft and handle are provided with a connecting mechanism 725 such as matching screw threads 103, 104 or any other attaching mechanism. A surgeon, manipulating both tools by their portions positioned outside the body, can connect them.

Once handle and tool are connect, the handle can be partially retracted from the body, pulling the operating tool head through the trocar and into the body cavity, as shown in FIG. 37. In FIG. 38 the tool is shown with operating head within the body cavity and free to move, it's handle being outside the body where it can be manipulated by a surgeon. FIG. 39 shows the tool approaching a surgical intervention site within the body cavity.

To remove the tool, the surgeon can use the handle to insert the operating head of the tool into the trocar, where he can grasp it from outside the body, and unscrew it or otherwise disconnect it from the handle. Thereafter both the tool and the handle can be removed from the body. The procedure can be used in introduce a plurality of such tools through a single trocar, enabling a surgeon to employ a plurality of tools with wide heads without needing a plurality of wide openings in the body cavity wall.

It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable subcombination or as suitable in any other described embodiment of the invention. Certain features described in the context of various embodiments are not to be considered essential features of those embodiments, unless the embodiment is inoperative without those elements.

Although the invention has been described in conjunction with specific embodiments thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the spirit and broad scope of the appended claims.

All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. To the extent that section headings are used, they should not be construed as necessarily limiting. 

What is claimed is:
 1. A method of performing surgery in a body cavity of a body, the body cavity being separated by a space outside the body by a body cavity wall, the method comprising: providing a surgical tool comprising a shaft and an operating head; inserting a trocar through the body cavity wall at a first location; inserting the shaft of the surgical tool from the space outside the body into the body cavity through the body cavity wall at a second location; directing the shaft of the surgical tool towards and through the trocar to the space outside the body cavity while inserted through the body cavity wall at a second location; attaching the operating head to the shaft of the surgical tool in the space outside the body cavity to form an assembled surgical tool; and withdrawing the operating head and the shaft of the assembled surgical tool back into the body cavity.
 2. The method of claim 1, further comprising utilizing the assembled surgical tool within the body cavity to perform an operation.
 3. The method of claim 2, further comprising removing the operating head from the shaft of the assembled surgical tool by passing the operating head through the trocar to a position outside the body cavity, and disconnecting the operating head from the shaft of the assembled surgical tool.
 4. The method of claim 1, wherein an internal diameter of the trocar is 4 mm or larger.
 5. The method of claim 1, wherein a size of an opening through the body cavity wall at a second location is smaller than a diameter of the trocar.
 6. The method of claim 1, wherein the operating head is at least one of a grasper, scissors, a coagulation device, a harmonic scalpel, a LigaSure, a needle holder, ligatures, a camera, and a suction device.
 7. The method of claim 1, wherein a width of the operating head is greater than a width of the shaft.
 8. The method of claim 1, wherein the shaft comprises a distal connecting mechanism for connecting to the operating head and a lumen for a movable control element attached to the operating head.
 9. The method of claim 1, wherein the body cavity wall is an abdominal wall.
 10. The method of claim 1, further comprising inserting a visual device into the body cavity through the trocar.
 11. A method of surgery, comprising: providing a surgical tool comprising a shaft and an operating head; inserting a trocar through a body cavity wall of a body cavity; inserting the shaft of the surgical tool through the body cavity wall at a location distant from the trocar, so that a proximal portion of the shaft is external to the body cavity; directing a distal portion of the shaft of the surgical tool towards and through the trocar to a space outside the body cavity; attaching the operating head to the shaft of the surgical tool while the distal portion of the shaft is in the space outside the body cavity; and withdrawing the operating head and the distal portion of the shaft of the surgical tool back into the body cavity.
 12. The method of claim 11, further comprising utilizing the operating head attached to the shaft within the body cavity to perform an operation.
 13. The method of claim 11, further comprising removing the operating head from the shaft of the surgical tool by passing the operating head through the trocar to a position outside the body cavity, and disconnecting the operating head from the shaft of the surgical tool.
 14. The method of claim 11, wherein the shaft of the surgical tool includes a sharp distal end configured to penetrate the body cavity wall.
 15. The method of claim 11, wherein an internal diameter of the trocar is 4 mm or larger.
 16. The method of claim 14, wherein the inserting of the shaft of the surgical tool through the body cavity wall of a body cavity includes forming an opening by penetrating the body cavity wall using the sharp distal end of the shaft.
 17. The method of claim 16, wherein a size of the opening through the body cavity wall at a location distant from the trocar is smaller than a diameter of the trocar.
 18. The method of claim 11, wherein the operating head is at least one of a grasper, scissors, a coagulation device, a harmonic scalpel, a LigaSure, a needle holder, ligatures, a camera, and a suction device.
 19. The method of claim 11, wherein a width of the operating head is greater than a width of the shaft.
 20. The method of claim 11, further comprising inserting a visual device into the body cavity through the trocar. 